Traffic Ed Forms at a GlancePrintable forms are attached for easy reference.

Please fax forms for quickest processing to (406) 265-3570.

Application for Admission New students who have never been admitted to MSU-Northern & plan to enroll in summer courses must complete an Application for Admission. Please click here to complete the Application for Admission online & submit all required documentation.

OR… Application for Re-admission

Former students who have been admitted to MSU-Northern but have not attended the preceding semester must submit an Application for Re-admission. Please click here to complete the Application for Re-admission online.

Class Registration Form Please complete this form to register for summer courses.

Student Insurance and Tuition Payment Form Please complete this form to confirm your attendance & pay your fees.

Residence Hall Application Form Please complete this form to reserve a room in the residence hall.

www.msun.edu

ONORTHERN Application for Admission Non-refundable $30 application fee required

(waived for Montana residents)

Personal Information

Full legal name ______________________________________ _ Last First Middle Previous/maiden name (s)

Birthdate (mo/day/yr) _______________ Birthplace _________________ _

Social Security Number----------------------------------­We ask that you voluntarily provide this number which permits MSUN to distinguish between individuals with similar names.

This is especially important should you request a transcript at a later date or wish lo be considered for financial aid.

Mailing Address--------------------------------------

City ___________ State ____ Zip _______ Phone Number ( )___ _

Note - all admissions correspondence will be sent to this address; please notify us of any changes

Permanent Address-------------------------------------

City ___________ State ____ Zip _______ Phone Number ( )_____ _

Cell Phone ( ) ______ _

E-mail ____________ @ ________ _

Country of Citizenship-----------------------------------

If not U.S., are you a permanent resident alien of the U.S.?

Educational Information

□ Yes □ No

Term of Enrollment: □ Fall 20 ______ _ □ Spring20 _____ _ D Summer 20 ______ _ Have you previously attended Montana State University-Northern? D Yes □ No

If yes, please list terms attended:--------------------------------

Application is for: D MSUN-Havre □ MSUN-Great Falls □ MSUN-Lewistown □ Other _______ _

Please indicate your educational goal: □ Associate's degree or Certificate (indicate field of study or undecided) ______________ _

□ Bachelor's degree (indicate field of study or undecided) ___________________ _

D Non-degree seeking (not pursuing a degree, certificate or financial aid at this institution)

D For personal/professional development

D For transfer to another institution

□ Post-baccalaureate (bachelor degree earned)

D Second bachelor degree (indicate field of study) _____________________ _

□ For Teacher Certification

□ Other _________________________________ _

Mail to: Montana State University-Northern • Admis.sions • P .0. Box 7751 • Havre, MT 59501-7751

1

Academic History If you are or will be a high school graduate, please indicate:

Graduation date ___ _,/ ___ -'----

High School name _____________________ City/State _____________ _

Is this high school accredited by its state department/office of education? □ Yes □ No

If you have or will receive a GED, please indicate date and location _____________________ _

If you have attended or are attending a College or University, please provide the following information for each institution,

whether or not credit was earned:

College (List full name please) �ity/State Attendance period Credits/Oe3ree( s)

eame

Were you ever suspended or dismissed for academic reasons from any of the institutions listed above? □ Yes □ No

If yes, please describe _______________________________________ _

Residency Classification

The information you provide will be used to assess your residency status for tuition and fee purposes only and has no effect on

admission. In addition to your own information, if your parents claim you as a tax exemption, provide information on your

parent or court appointed guardian, or information on your spouse if applicable.

With whom do you make your permanent residence? _______________ Relationship ________ _

Are you a Montana resident? □ Yes □ No lfno,ofwhat state are you a resident? _________ (Proceed to number 3. a.)

Failure to complete the following information may result in your being misclassified. You may also be asked to complete a Residency Questionnaire. (Month and year are sufficient for dates more than two years past.)

You NA Parent/Guardian/Spouse NA

a. Dates of continuous physical residence in Montana (mo/day/yr). _ !_!_ to_!_! __ □ _ !_!_ to_!_! _ □

b. Dates of employment in Montana (mo/day/yr)._/_/_ to_/_/ __ □

_ /_/_ to_/_/ _ □

□ Full-time □ Part-time

Your Employer City □ Other

□ Full-time□ Part-time

The Employer of your Parent(s), Guardian(s), or Spouse City □ Other

c. List the last two years Montana Income tax returns have been filed. and □ and □

d. Date current Montana Driver's License was issued. □ □

e. List the last two years of Montana Motor Vehicle Registration. and □ and □

f. Date of Montana voter registration. □ □

g. Date of extended absence(s) from Montana during the last two years. _ !_!_ to_!_!_ □ _!_!_ to_!_! _ □

Reason for absence: ______________________________________ _

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Voluntary Statistical Information

Montana institutions of higher education using this application do not discriminate in admjssion or the provision of services nor employment policies on the basis of race, gender, national origin, marital status, creed, religion, color, age or physical or

mental handicap. Providing the following information requested by this section is voluntary and the information provided is for statistical analysis only.

Gender: □ Male □ Female Religious preference:

Have either of your parent(s) or guardian(s) completed a bachelor's degree? D Yes

Indicate your ethnic identity:

D No D Unsure

□ Hispanic or Latino

□ Not-Hispanic or Latino

Indicate all races that apply among the following:

□ White

□ American Indian or Alaska Native (specify primary tribal affiliation and reservation) ___________ _

D Black or African American

D Asian (specify country of origin) _______________________________ _

D Native Hawaiian or other Pacific Islander (please specify) _____________________ _

D Other (please specify)---------------------------------

Admissions Checklist

Before you may be accepted to MSU-Northern, you will need to

provide the following documentation:

All Applicants: □ COMPLETED Application for Admission

D $30 Application Fee (waived for Montana residents)

D Proof of immunization against measles, mumps and rubella

(MMR) for students born after December 31, 1956.

(Montana State Law requires proof of two MMR immunizations,

at lea<;t 1 month apart or a notarized religious exemption.)

First-Time Applicants: □ Final High School transcript or GED scores

□ ACT or SAT scores for students under the age of 21

Transfer Applicants: D Official academic transcripts from all ACCREDITED

universities, colleges and vocational technical centers

attended (Official college transcripts must be sent to the

Admissions Office in a sealed envelope directly from the

institution).

Please note: If you have earned less than 12 credits at a

college, university or vo-tech, you must also submit a high

school transcript or GED scores and ACT or SAT scores.

Questions: 1-800-662-6132 ext. 3704

or (406) 265-3704

admissions@msun.edu

Fax: (406) 265-3788

4

Disclosure Information

In accordance with the Family Educational Rights &

Privacy Act of 1974, the Registrar informs students that the

University may disclose information from the educational

record of a student who is or has been in attendance at

Montana State University-Northern. The following

information is considered by the University to be public in

nature:

• Name

• Address

• Telephone number

• Year in school

• Major

• Scholarship(s) awarded

• Degree(s) conferred

• Honor(s) granted

• Dates attended

Students have the right to refuse to permit the University from

disclosing the above information. This is an "all or nothing"

policy. The student may not select certain information or

certain circumstances for non-disclosure. The student's name

will not appear on any lists released to third parties, including

honor rolls and will not receive emergency messages.

Students must fill out a "Privacy Rights Request Form" (from

the Registrar's Office) to refuse to permit the University to

disclose the above information.

Application for Re-admission

Personal Information

Name (Last, First, Middle or Maiden)

Date of Birth (mo/day/yr) SSN or Banner ID

Mailing Address

City State Zip Phone Number ( )

Cell Phone ( ) E-mail

Gender (optional): ❏ M ❏ F Ethnic Identity (optional): ❏ Hispanic ❏ Non-Hispanic

Indicate Race(s) (optional): ❏ White ❏ American Indian/Alaskan Native ❏ African American ❏ Asian ❏ Hawaiian Pacific Islander ❏ Other

Educational Information

Indicate term you plan to attend: ❏Fall Semester______ ❏Spring Semester______ ❏Summer Semester______

Indicate Level: ❏ Undergraduate ❏ Graduate Intended Status: ❏ Degree-Seeking ❏ Non-Degree

Intended Degree/Major: Or Certification/Endorsement: ❏ Re-Certification ❏ Traffic Ed

Indicate site planning to attend: ❏Havre ❏Great Falls ❏Lewistown ❏Other(Please specify):

Have you earned credit from any institution since last attending MSU-Northern? ❏Yes ❏No If yes, list all post-secondary institutions attended, specifying campus and dates of enrollment.

Name of Institution Location (City/State) Attended From (mm/yyyy) Attended To (mm/yyyy) Credits/Degree Earned

Were you ever suspended or dismissed for academic reasons from any of the institutions listed above? ❏Yes ❏No If yes, (term/yyyy)

Residency Classification

U.S. Citizen ❏ Yes ❏ No If no, country of citizenship

In which state are you a resident of?

What year and state did you last pay taxes?

Required Safety and Security Information

Have you ever been convicted of a felony (include instances of deferred sentencing)? ❏Yes ❏No

Have you ever been subjected to court-ordered confinement for threatening

or causing physical or emotional injury to persons or property? ❏Yes ❏No

Have you ever been disciplined, suspended from, or placed on probation at any

post-secondary educational institution for non-academic reasons? ❏Yes ❏No

Have you ever been required to register as a sexual or violent offender? ❏Yes ❏No

An affirmative response to any of these questions will not automatically prevent admission, but you will be asked by the college to provide additional information. This information will be reviewed by a campus committee to ensure campus safety. Any falsification or omission of data may result in a denial of admission or dismissal.

Signature I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or misrepresentation. I understand that if it is later found otherwise, it is sufficient cause for rejection or dismissal. If my application for re-admission is approved, I agree to abide by the present and future rules and regulations, both academic and nonacademic, and the scholastic standards of MSU-Northern including but not limited to those rules, regulations and standards stated in the catalog. I further acknowledge that if I fail to adhere to these regulations or meet these requirements, my registration may be canceled. Applicant’s Complete Legal Signature Date

Questions: Call the Admissions Office at 1-800-662-6132 ext. 3704 or (406) 265-3704 FAX: 1-406-265-3792 Mail: Montana State University-Northern, Admissions, PO Box 7751, Havre, MT 59501

Revised: 03/07/2016

Term of Registration: □ Fall □ Spring □ Summer Year: 20

Name Last: First: Middle Initial: ID:

Please update the following information: Mailing Address (while at school): Permanent Address:

CRN SUBJ NUM SEC Course Name Crs Time Days Instructor Room Rpt/

Aud

Total Credits

Student Signature: Advisor Signature: ______________________________ Education Dean Signature (All ED majors): ________________________________________________ Registrar verification: _____________________________________ Date: __________________________________

Address: Address: City: City: State: Zip: Phone: State: Zip: Phone:

Social Security Number (Optional): Gender: □ Male □ Female

Ethnic Code: □ Caucasian □ Hispanic □ Black □ Asian □ American Indian/Alaska Native □ Other □ Decline to respond

Preferred Email Address:

CLASS REGISTRATION

(use standard blue or black pen)

Name: Student ID#:

Permanent Mailing Address: Phone #:

2. Student Health Insurance☐ I choose to waive health insurance offered by MSU-Northern, I have health insurance from another

provider in effect for the duration of this semester.☐ I choose to retain the health insurance offered by MSU-Northern.

All students registered for 6 or more credits are required to have health insurance. A health policy is offered through MSU-Northern and the premium for this program will automatically be assessed to students with 6 or more credits unless waived with this form. Waivers will not be accepted after the 15th day of instruction.Coverage is optional for students registered for 4-6 credits. Students taking 3 or fewer credits must petition to purchase desired coverage.

3. Method of Payment☐ Cash or Check ☐ Financial Aid

☐ Credit Card (Visa/MasterCard accepted. Visit Business Services, Cowan Hall 207 or call 406.265.3733)

☐ Third Party Billing Program:

References:

Parent/ Relative:Name: Address Telephone#

Person who will always know

your address:

Name: Address Telephone#

Employer:Address Telephone#

1. Personal Information

4. Signature RequiredI will be attending MSU-Northern for the current semester. I have read and agree to the terms of this document. Please apply my Aid/Third Party billing/ Enclosed Payment to my charges.

Signature:____________________________________________________________________ Date:________________________

E-mail:

Semester:☐Fall☐Spring☐SummerYear:

DELIVER COMPLETED FORM TO: BUSINESS SERVICES, COWAN HALL 207 - FAX TO: 406.265.3777EMAIL TO: BUSINESSSERVICES@MSUN.EDU OR STUDENT.ACCOUNTS@MSUN.EDUMAIL TO: MONTANA STATE UNIVERSITY-NORTHERN • PO BOX 7751 • HAVRE, MT, 59501

Name:

Vehicle Make/Model ColorLicense Plate # State

☐ InstallmentsI request that MSU-Northern allow me to defer a portion of my tuition/fees and student account charges. I Installment Payment Schedule:understand that, in doing so, I am entering into an educational loan with MSU-Northern that is non-dischargeable under Section 523(a)(8) of the U.S. Bankruptcy Code. I agree to all the terms and conditions of this contract. Payment DueMy signature will signify my consent to and acceptance of these terms and conditions and also authorize MSU-Northern to use my social security number for internal and external credit reporting and collection purposes Initial Installment Friday before classes begin for all charges incurred against my account for the duration of my enrollment at MSU-Northern. If this account is referred to a collection agency, I will be responsible for the reimbursement of the fees of any collection agency Second Installment 30 daysup to 40%, which may be based on a percentage of the debt, and all costs and expenses, including reasonableattorney’s fees that the University should incur in such collection efforts. I authorize MSU-Northern, and their Third Installment 60 daysrespective agents and contractors to contact me regarding my student loan(s), student account or any balance owed to MSU-Northern including repayment of my loan and student account, at the current or any future number Final Installment 90 dayseither provided or acquired for my cellular phone or other wireless devices using an automated telephone dialing equipment or artificial or prerecorded voice or text messages. I understand that any funds that become available, including but not limited to: payroll checks, Financial Aid, and book buy-back refunds, will first be applied to my account balance regardless of the due date. I agree that a service charge of $30 will be applied to all installment contracts each semester, and that every late payment may be assessed a $15 late charge. Other penalties for non-payment include denial of registration and transcripts, denial of future installment contracts, referral to a collection agency, attachment of state and federal income tax refunds, and reporting to a credit bureau. I understand that in order to register for the upcoming semester(s) my account balance must be $200 or less. In the event that I withdraw or leave school for any reason, refunds will be applied to the outstanding balance, and any remaining balance remains due and payable. WE RECOMMEND YOU KEEP A COPY OF THIS FORM. MSU-Northern reserves the right to decline any installment loan application.

STUDENT CONFIRMATION AND PAYMENT AGREEMENT

_

Residential Education Summer Residence Hall Application Revised 2021

RESIDENCE HALL APPLICATION Summer Semester 2021

Please bring your own bedding and toiletries as we do not provide them. All rooms will be single occupancy unless you have identified a roommate who has also identified you as their preferred roommate. Completion of this application does not guarantee availability of residence hall space. We will confirm your room once it has been assigned.

PERSONAL INFORMATION:

Student ID:_______________________ Last Name:________________________________________________

First Name: _____________________________ Middle Initial: ________Preferred Name: _________________

Birth Date: ____________ Gender:____ Home Phone: ( )_____________ Cell Phone: ( )_____________

Permanent Address: ___________________________City:___________________ State:_____ Zip Code:_____

ROOMMATE PREFERENCE (BOTH note this preference) Name: _______________________________________

MSUN STUDENTS ONLY

STUDENT STATUS/LEVEL OF STUDY (MSUN Students only):

□ New Student □ Former MSUN Student □ Transfer □ Continuing Education □ Graduate

□ Freshman (0-30 credits) □ Sophomore (31-60 credits) □ Junior (61-90 credits) □ Senior (91-120+ credits)

DATE SELECTION:

□ Entire Summer: May 17-August 13 (single occupancy)

□ May Session: May 17-June 4

□ 1st Session: June 7-July 9

□ 2nd Session: July 12-August 13

□ Full Session: May 17-August 13

CONFERENCING AND CAMPS ONLY

Group/Organization: ________________________________________________________________________

Group Organizer/Host: ______________________________________________________________________

DATE SELECTION: Daily room rates: $30.00 per night single occupancy Please indicate the dates you need a room.

Month: _____________________ Day: ________ through Month: ___________________ Day: ___________

Residential Education Summer Residence Hall Application Revised 2021

EMERGENCY CONTACT:

Name: __________________________________ Relationship: _________________ Phone: _______________

VEHICLE INFORMATION:

Make:________________________ Model: _____________________________________ Year: __________

Color: _______________________ License Plate #: _______________________ State:__________________

. PAYMENT INFORMATION (Conferencing/Camps only): Total Charge: _________ On student account: _____ Paid in advance: _____ Date: __________ Receipt: ______ Unless you are enrolled in classes, a camp, or workshop, you must pay in advance. Payment for housing must be paid at Business Services, Room 207 Cowan Hall. If you wish to pay by credit or debit card, please call Business Services at 406-265-3733. Make checks payable to Montana State University-Northern and remit to:

MSU-N Student Life Office P.O. Box 7751

Havre, MT 59501 RETURN THIS FORM TO: Taryn Wallon, Residential Education Student Union Building or Email: Taryn.wallon@msun.edu IF YOU NEED TO CHANGE ANY INFORMATION (INCLUDING ROOM RESERVATION DATES) AFTER THIS FORM HAS BEEN SUBMITTED, PLEASE CONTACT RESIDENTIAL EDUCATION OFFICE AT 406-265-3539 By signing this application, you are acknowledging that you have read, understood, and agree that you are responsible for complying with the MSU-Northern Student Conduct Code and the Student Life Handbook: Community Standards and Expectations as well as state and federal laws. The Student Conduct Code can be found at: https://www.msun.edu/deanse/studentconduct.aspx The Student Life Handbook can be found at: https://www.msun.edu/housing/docs/Student-Life-Handbook19-20.pdf __________________________________________________ _________________________ Student/Guest Signature Date __________________________________________________ _________________________ Parent/Guardian Signature (If you are under 18 years of age) Date

RESIDENCE LIFE STAFF ONLY Date Application Received: _________ Room Assignment: __________________________ Date Housing Deposit Received: _________ FOB Assignment: ____________ Vehicle Information Received: ________ Cleared by Business Office: ____________